Porter, John s
NEW YORK STATE DEPARTMENT OF HEALTH `
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r John Porter Male
':? Date of Death Age If Veteran of U.S. Armed Forces,
$r1 August 27, 2014 89 War or Dates t��rij
iPlace of Death Hospital, Institutiorindian River Rehab & Health Care
City, Town or Village Granville Street Address Center. Inc.
Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
.•ti Death Certificate Filed ' J District Number Register ber
City, Town or Village Village of Granville 5725 p(7
❑Burial Date Cemetery or Crematory
Ill Entombment August 28, 2014 Pine View Crematory
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
P: Hold
Cl)
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
rrr Permit Issued to Registration Number
:•: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
✓ Address
▪ 53 Quaker Road,Queensbury,NY 12804
.tir Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
Address
r' Permission is he eby granted to dispose of the human remai s dea ri ov as indjcated.
r{•.
{s: Date Issued / Registrar of Vital Statistics ��
:'{: (signature)
District Number 5725 Place Village of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�z U er
Date of Disposition $�Zq�l�/ Place of Disposition ,,.�, ��,
W (address)
Cl)
CL (section) I (lot number) (grave number)
GName of Sexton or Person in Charge of Premises �r,{�t�0j,,� 3aKbi
'Z (pldase print)
Signature i t4 / Title CRC-/17f
(over)
DOH-1555(02/2004)